Racial/Ethnic Disparities Continue in NICU Care

Tara Haelle

July 29, 2019

Racial and ethnic disparities persist in the quality of care received by infants in US neonatal intensive care units (NICUs), according to a systematic review published today in Pediatrics. These disparities most often disadvantage African American infants and, possibly to a lesser extent, other infants of color, the researchers say.

The disparities center on two overarching themes, write Krista Sigurdson, PhD, of Stanford University and Lucile Packard Children's Hospital in Palo Alto, California, and colleagues.

"First, infants of color, especially black and Hispanic infants, are more likely to receive care in quality-challenged hospitals," they write. "Second, disparities also exist within NICUs. Although some overlap exists, strategies to address disparities may differ."

They acknowledge socioeconomic differences may confound some of the findings but found plenty of evidence suggesting quality improvement initiatives can help providers ameliorate the disparities and poor outcomes for infants of color.

The authors also note the potential hazard of using the term "disparities," which might incorrectly imply that the differences in outcomes are "natural" and therefore difficult or impossible to improve. 

"For instance, differences can be naturalized through racially biased preconceptions about cultural behaviors or biological causes and their impact on health disparities," the authors warn.

The researchers included 41 studies in their review. "Measuring quality of care is nuanced and this literature cannot always isolate measures or disparities strictly related to quality of neonatal care, biological diversity, maternal comorbidities or a challenged socioeconomic environment," they explain. "In determining which articles to include or exclude, we relied on expert assessments of measures of quality and the principle that quality measures should be malleable."

Wide Range of Disparities Identified

Although the studies were too heterogenous for a qualitative analysis, the authors analyzed them in three separate groups on the basis of whether the research examined structure, process, or outcomes in the NICU.

A dozen articles explored how the structure of health systems affects racial/ethnic disparities in NICU care and identified multiple patterns. Hospitals primarily serving African-American infants tended to have poorer practice environments, more nurse understaffing, and higher patient-to-nurse ratios. Risk-adjusted neonatal mortality rates were significantly higher in hospitals whose patients with very low birth weight (VLBW) included more than 35% of black infants, compared with hospitals with less than 15% black infants comprising their VLBW neonate population.

Nineteen studies that focused on NICU care processes also uncovered multiple factors contributing to racial/ethnic disparities. Breast-feeding rates were highest for infants of all races/ethnicities in hospitals with predominantly white mothers. African American mothers tended to receive "limited breastfeeding education and support during pregnancy, childbirth, NICU stays, postpartum, and recovery in the community." Black mothers were less likely to consent to donor milk and were more likely to be discouraged from kangaroo care; NICUs in communities with the lowest proportion of black residents had the highest rates of breast-feeding and donor milk use.

Reports on racial disparities in the delivery of surfactant for respiratory distress syndrome were conflicting, though research did consistently find that black infants appeared less likely to benefit from it compared with white infants.

Finally, the 11 studies examining racial/ethnic outcome disparities found that black infants were twice as likely to die from intraventricular hemorrhage than white infants and that Latino infants with necrotizing enterocolitis were twice as likely to die than black or white infants. Rates of necrotizing enterocolitis, retinopathy of prematurity, and chronic lung disease were also higher in Alaskan Native infants than in non-Native infants. Studies offered contradictory findings on various other outcomes, with some showing racial/ethnic disparities and others showing no differences between demographic groups.

A Path Toward Improvement

Racism has long been identified as a social determinant of health, the American Academy of Pediatrics (AAP) notes in a policy statement published alongside the study. The statement acknowledges some progress toward reducing racial inequities but states that institutional and interpersonal racism, as well as implicit and explicit biases, continue to harm the health and well-being of infants of color. 

"These findings are not surprising given that clinical care operates in a social context of structural racism and implicit bias," write Wanda D. Barfield, MD, and colleagues from the Centers for Disease Control and Prevention in an accompanying editorial. They note that similar disparities occur in maternal healthcare delivery.

In fact, in a study published July 25 in the American Journal of Preventive Medicine, Jaime C. Slaughter-Acey, PhD, MPH, from the School of Public Health, University of Minnesota, Minneapolis, and colleagues, found that even skin tone influences access to care. A quarter of the black African American women in the study received delayed prenatal care, but those with lighter brown and darker (but not medium) brown shades had a higher risk for delayed care.

Yet quality-improvement efforts can reduce or eliminate these disparities, Barfield and colleagues write.

"Some studies revealed that when care is received in facilities with comparable levels of care and quality, infant survival for those of color is equal to that for white infants, and in some cases is higher," they explain. They recommend five actions to improve NICU care for all infants, starting with getting rid of the myth that African American premature infants have "an inherent advantage…of survival," a false assumption that can bias delivery of care.

They also recommend that quality improvement interventions be initiated with "a lens toward health equity," such as making sure such initiatives include hospitals that predominantly serve minorities. "Requiring all hospitals in a state to participate in these initiatives [such as state perinatal quality collaboratives] is a strategy for equitable diffusion," they write.

Barfield and colleagues further note the importance of choosing measures that accurately reflect the "type and quality of care" infants receive, such as time to receive effective interventions and caregivers' satisfaction. "Comparisons within and among facilities can inform targets and best practices for improving quality of care," they write.

Finally, the editorialists advise "that all infants receive care in risk-appropriate facilities" and that research be employed to uncover what drives disparities and what solutions address those disparities.

"It is important to consider the implementation of quality-improvement efforts to ensure that they do not increase disparities," they write. "Stratification of outcomes by race and/or ethnicity or other demographic factors is important to demonstrate improvements among groups at the highest risk for poor outcomes."

The editorialists' advice was echoed in the recommendations of the AAP policy statement. The organization discussed ways for pediatricians to optimize clinical practice, including the creation of culturally safe medical homes that are sensitive to the reality of institutional and social racism and explicitly screen for social determinants of health, including perceived and experienced racism. The AAP also advises training clinical and office staff to provide culturally and linguistically competent care and use a variety of strategies to support families of color.

The AAP calls for workforce development and professional education at state and national levels that can help pediatricians "deliver culturally appropriate and patient- and family-centered care." The organization also emphasizes the importance of partnerships, community engagement, and policy advocacy to address social and institutional contributors of racism.

Like Barfield and colleagues, the AAP calls for more research that can inform solutions to race-related disparities in care, including workforce development activities; understanding the impact of discrimination and race identity on health access and outcomes; identifying the impact of policy changes and interventions; and relying more on biomarkers, rather than race/ethnicities, identified through human genome research to guide risk assessment and care.

"Quality improvement for adult patient care has revealed, when implemented with a specific eye on 'closing the gap,' that disparities can be reduced," Barfield and colleagues conclude. "We owe the infants of this country consistent high-quality care, no matter their skin color."

The research was funded by the Stanford Maternal and Child Health Research Institute, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institutes of Health. The authors have disclosed no relevant financial relationships.

Pediatrics. Published July 29, 2019. Abstract, Editorial, AAP Policy Statement

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